Communication strategy for implementing community IMCI

In resource-poor developing countries, significant improvements in child survival, growth, and development can be made by: (a) shifting from sectoral programmes (for example, in nutrition or immunization) to holistic strategies such as the Integrated Management of Childhood Illnesses (IMCI) and (b) improving household and community care and health-seeking practices as a priority, while concurrently strengthening health systems and the skills of health professionals. This article focuses on household and community learning, and proposes a communication strategy for implementing community IMCI (c-IMCI) that is based on human rights principles such as inclusion, participation, and self-determination. Rather than attempt to change the care practices and health-seeking behaviour of individuals through the design and delivery of messages alone, it proposes an approach that is based on community engagement and discussion to create the social conditions in which individual change is possible. The strategy advocates for the integration of sectoral programmes rather than the development of new holistic programmes, so that integrated programmes are created from "multiple entry points". As integration occurs, the participatory communication processes that are used in sectoral programmes can be enriched and combined, improving the capacity of governments and agencies to engage community members effectively in a process of learning and action related to child health and development.     

Research to support household and community IMCI. Report of a meeting, 22-24 January 2001, Baltimore, Maryland, USA

The Integrated Management of Childhood Illness (IMCI) strategy combines improved case management of childhood illness with aspects of nutrition, immunization, disease prevention, and promotion of growth and development. The household and community component of IMCI was formulated to reach the numerous sick children who are ill and often die at home without ever being treated by a trained healthcare practitioner. In January 2001, USAID (Child Health Research Project and BASICS II) and the CORE Group sponsored a meeting in Baltimore, Maryland, to determine the research needed to implement household and community IMCI effectively. This paper summarizes the presentations at that meeting and highlights the research and programme priorities expressed using the three-element approach devised by the CORE Group and USAID (BASICS II and Child Survival Technical Support Project). Research priorities to improve partnerships between health facilities and the communities they serve (Element 1) include finding ways to increase community involvement and management of health facilities, establishing accurate costs for community IMCI services, and formulating cost-recovery mechanisms tailored to local circumstances. Programme priorities in Element 1 include establishment of systems for maintenance of an adequate supply of essential equipment and medicines, while retaining access for the poor and ensuring adequate referral mechanisms for severely-ill patients that include monitoring and incentives for the performance of health workers. Research priorities to increase appropriate, accessible care and information from community-based care providers (Element 2) consist of activities to design simplified IMCI guidelines for use by community health workers (CHWs) and volunteers and evaluation of the impact of using these guidelines on morbidity and mortality. Also a priority item in this category is experimenting with ways to teach mothers and families to care for sick children at home and strategies to improve the practice of medicine in the private sector. More research is also needed to improve the quality of nutritional and preventive health counselling given by CHWs and to find ways to make community IMCI interventions sustainable. Programme priorities in Element 2 include efforts at the national level to establish policies to improve care by traditional and private care providers and to define the position of volunteer workers in the national health system. Research priorities to integrate promotion of key family practices critical for public health (Element 3) are focused on determining which interventions are the most effective in reducing child morbidity and mortality at the household and community levels, finding the best methods of delivering these interventions, and implementing these and scaling up in essential service packages. Particular issues in child health, needing urgent attention from the research and programme communities, are HIV/AIDS and neonatal morbidity and mortality.     

Impact of a community-based comprehensive primary healthcare programme on infant and child mortality in Bolivia

Community-based comprehensive primary healthcare programmes are a widely-promoted strategy for improving child survival in less-developed countries, but limited documentation exists concerning their effectiveness in actually reducing child mortality. This study examined the impact of a community-based comprehensive primary healthcare programme on child survival in Bolivia. Mortality rates from two intervention areas where Andean Rural Health Care (ARHC) had been conducting child-survival activities for 5-9 years were compared with those from two geographically-adjacent comparison areas that lacked such activities and that were virtually identical to the intervention areas in socioeconomic characteristics. Vital events were registered at the time of regular visit to all homes. In the comparison areas, limited services were available which reached only a small percentage of the population, while in the intervention areas, prenatal care, immunizations, growth monitoring, nutrition rehabilitation, and acute curative services were readily available to the entire population. In 1992-1993, the annual rates of mortality of children, aged less than five years, were 205.5 per 1,000 and 98.5 per 1,000 in the comparison and intervention areas respectively. The absolute difference in mortality of 107.0 deaths per 1,000 (95% confidence interval [CI], 72.7-141.3 per 1,000) represented 52.1% (95% CI, 35.2-68.8%) lower mortality of children aged less than five years in the intervention areas compared to the control communities. These results suggest that the provision of community-based, integrated health services can significantly improve child survival in poor countries. Better-designed and larger field trials of community-based comprehensive primary healthcare programmes in multiple regions of the world are needed to provide a stronger scientific basis for developing this approach further in developing countries.     

The integrated management of childhood illness: Haiti's example

Child health in developing countries is a public health priority both at the national and international level. The World Health Organization, UNICEF and other technical partners have developed The Integrated Management of Childhood Illness (IMCI) strategy to reduce child mortality and improve child health and development through a holistic approach. By the end of 2002, 109 countries among which 17 in the region of the Americas and Caribbean had adopted and implemented this strategy,. In this region, Haiti presents the highest mortality rate for under-fives. Every year, more than 138,000 children die of diseases such as malaria, pneumonia, diarrhea, measles and perinatal complications. Malnutrition contributes to a high percentage of these deaths. It is recognised that the mortality due to these diseases can be prevented. To fight this burden, Haiti officially adopted the IMCI strategy in 1997. The objectives of this paper are, after a general overview of the IMCI strategy, to describe Haiti's child health and analyse the achievements of the first steps of implementing the IMCI strategy in Haiti. The methodology used was a standardised literature review and a qualitative survey based on semi-structured interviews of national and local health authorities involved in the implementation of the IMCI strategy in Haiti. Main results show a limited impact of the first and second phase of implementation in the country. The key factors for this have been limited economical and human resources. A unequal distribution of existing resources between the different IMCI strategy components especially community and family practices, has limited adequate coverage. Isolated actions in favour of child health as well as a lack of co-ordinated interventions between the various actors have been among the barriers for an adequate implementation of this strategy. We recognise that the approach used here is not a formal evaluation on the implementation of IMCI in Haiti. Nevertheless, we hope this article will contribute to draw the attention of national and international public health decision-makers on the difficulties of implementing this strategy in Haiti and in this way, improve child health in the country.     

Equity and child-survival strategies

Recent advances in child survival have often been at the expense of increasing inequity. Successive interventions are applied to the same population sectors, while the same children in other sectors consistently miss out, leading to a trend towards increasing inequity in child survival. This is particularly important in the case of pneumonia, the leading cause of child death, which is closely linked to poverty and malnutrition, and for which effective community-based case management is more difficult to achieve than for other causes of child death. The key strategies for the prevention of childhood pneumonia are case management, mainly through Integrated Management of Childhood Illness (IMCI), and immunization, particularly the newer vaccines against Haemophilus influenzae type b (Hib) and pneumococcus. There is a tendency to introduce both interventions into communities that already have access to basic health care and preventive services, thereby increasing the relative disadvantage experienced by those children without such access. Both strategies can be implemented in such a way as to decrease rather than increase inequity. It is important to monitor equity when introducing child-survival interventions. Economic poverty, as measured by analyses based on wealth quintiles, is an important determinant of inequity in health outcomes but in some settings other factors may be of greater importance. Geography and ethnicity can both lead to failed access to health care, and therefore inequity in child survival. Poorly functioning health facilities are also of major importance. Countries need to be aware of the main determinants of inequity in their communities so that measures can be taken to ensure that IMCI, new vaccine implementation and other child-survival strategies are introduced in an equitable manner.     

The effect of Integrated Management of Childhood Illness on observed quality of care of under-fives in rural Tanzania

Integrated Management of Childhood Illness (IMCI) has been adopted by over 80 countries as a strategy for reducing child mortality and improving child health and development. It includes complementary interventions designed to address the major causes of child mortality at community, health facility, and health system levels. The Multi-Country Evaluation of IMCI Effectiveness, Cost and Impact (IMCI-MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. The MCE is coordinated by the Department of Child and Adolescent Health and Development of the World Health Organization. MCE studies are under way in Bangladesh, Brazil, Peru, Tanzania and Uganda. In Tanzania, the IMCI-MCE study uses a non-randomized observational design comparing four neighbouring districts, two of which have been implementing IMCI in conjunction with evidence-based planning and expenditure mapping at district level since 1997, and two of which began IMCI implementation in 2002. In these four districts, child health and child survival are documented at household level through cross-sectional, before-and-after surveys and through longitudinal demographic surveillance respectively. Here we present results of a survey conducted in August 2000 in stratified random samples of government health facilities to compare the quality of case-management and health systems support in IMCI and comparison districts. The results indicate that children in IMCI districts received better care than children in comparison districts: their health problems were more thoroughly assessed, they were more likely to be diagnosed and treated correctly as determined through a gold-standard re-examination, and the caretakers of the children were more likely to receive appropriate counselling and reported higher levels of knowledge about how to care for their sick children. There were few differences between IMCI and comparison districts in the level of health system support for child health services at facility level. This study suggests that IMCI, in the presence of a decentralized health system with practical health system planning tools, is feasible for implementation in resource-poor countries and can lead to rapid gains in the quality of case-management. IMCI is therefore likely to lead to rapid gains in child survival, health and development if adequate coverage levels can be achieved and maintained.     

Integrated management of childhood illness: a summary of first experiences.

The strategy of Integrated Management of Childhood Illness (IMCI) aims to reduce child mortality and morbidity in developing countries by combining improved management of common childhood illnesses with proper nutrition and immunization. The strategy includes interventions to improve the skills of health workers, the health system, and family and community practices. This article describes the experience of the first countries to adopt and implement the IMCI interventions, the clinical guidelines dealing with the major causes of morbidity and mortality in children, and the training package on these guidelines for health workers in first-level health facilities. The most relevant lessons learned and how these lessons have served as a basis for developing a broader IMCI strategy are described.     

Implementation of the Integrated Management of Childhood Illness strategy in Peru and its association with health indicators: an ecological analysis

The Multi-Country Evaluation of Integrated Management of Childhood Illness (IMCI) Effectiveness, Cost and Impact (MCE) was launched to assess the global effectiveness of this strategy. Impact evaluations were started in five countries. The objectives of the Peru MCE were: (1) to document trends in IMCI implementation in the 24 departments of Peru from 1996 to 2000; (2) to document trends in indicators of health services coverage and impact (mortality and nutritional status) for the same period; (3) to correlate changes in these two sets of indicators, and (4) to attempt to rule out contextual factors that may affect the observed trends and correlations. An ecological analysis was performed in which the units of study were the 24 departments. By 2000, 10.2% of clinical health workers were trained in IMCI, but some districts showed considerably higher rates. There were no significant associations between clinical IMCI training coverage and indicators of outpatient utilization, vaccine coverage, mortality or malnutrition. The lack of association persisted after adjustment for several contextual factors including socioeconomic and environmental indicators and the presence of other child health projects. Community health workers were also trained in IMCI, and training coverage was not associated with any of the process or impact indicators, except for a significant positive correlation with mean height for age. According to the MCE impact model, IMCI implementation must be sufficiently strong to lead to an impact on health and nutrition. Health systems support for IMCI implementation in Peru was far from adequate. This finding, along with low training coverage level and a relatively low child mortality rate, may explain why the expected impact was not documented. Nevertheless, even districts with high levels of training coverage failed to show an impact. Further national effectiveness studies of IMCI and other child interventions are warranted as these interventions are scaled up.     

Community-based interventions for diarrhoeal diseases and acute respiratory infections in Nepal

Problem

Acute diarrhoeal diseases and acute respiratory infections (ARIs) are the most common causes of child mortality worldwide. Safe, effective and inexpensive solutions are available for prevention and control, but they do not reach needy communities.

Approach

Interventions based on research were designed to train and engage community health volunteers (CHVs) to implement a community-based control programme in Nepal. With the advent of the Integrated Management of Childhood Illnesses (IMCI) strategy, this programme subsequently emerged as a community-based IMCI but retained its mainstream activities. We reviewed and analysed policy decisions and programme development, implementation and expansion.

Local setting

Severe resource constraints and difficult terrain limit access to health-care facilities in many parts of Nepal.

Relevant changes

In districts with interventions, more cases of acute diarrhoea and of ARIs (including pneumonia) were reported. The proportion of diarrhoea cases with dehydration and the proportion of ARI cases with pneumonia were significantly lower in districts with interventions. Case fatality rates due to acute diarrhoea and the proportion of severe pneumonia among ARI cases across the country showed a significant trend towards a decrease from 2004 to 2007. Nepal has succeeded in training many CHVs and is on course to meet the Millennium Development Goal for child mortality.

Lessons learnt

The burden of acute diarrhoea and ARIs can be reduced by training and engaging CHVs to implement community-based case management and prevention strategies. Monitoring, supervision and logistical support are essential. Policy decisions based on evidence from national research contributed to the success of the programme.     

Strengthening human resources for health systems resilience to care for mothers and children

Community-based strategies that foster frequent contact between caregivers of children under five and provide credible sources of health information are essential to improve child survival. Care Groups are a community-based implementation strategy for the delivery of social and behavior change interventions. This study assessed if supervision of Care Group activities by Ministry of Health (MOH) personnel could achieve the same child health outcomes as supervision provided by specialized non-governmental organization (NGO) staff. The study was a pretest-posttest quasi-experimental design implemented in Burundi. A total of 45 MOH-led Care Groups with 478 Care Group Volunteers (CGVs) were established in the intervention area; and 50 NGO-led Care Groups with 509 CGVs were formed in the comparison area. Data were collected from 593 and 700 mothers of children 0-23 months at baseline and endline, respectively. Pearson’s chi-squared test and difference-in-difference analysis assessed changes in 40 child health and nutrition outcomes. A qualitative process evaluation was also conducted midway through the study. The MOH-led Care Group model performed at least as well as the NGO-led model in achieving specific child health and nutrition outcomes. Mothers of children 0-23 months in the intervention and comparison sites reported similar levels of knowledge and practices for 38 of 40 dependent variables measured in the study, and these results remained unchanged after accounting for differences in the indicator values at baseline. Process monitoring data confirmed that the MOH-led Care Group model and the NGO-led Care Group model were implemented with similar intervention strength. The study demonstrated that behavior change interventions traditionally led by NGOs can be implemented through the existing MOH systems and achieve similar results, thereby increasing the potential for sustainable child health outcomes. Future research on the MOH-led Care Group model is required to systematically document all inputs and monetary costs borne by the MOH to implement the model.     

Impact of IMCI health worker training on routinely collected child health indicators in Northeast Brazil

The Integrated Management of Childhood Illness (IMCI) is a global strategy including improvements in case management at health facilities, strengthening health systems support and improving key family and community practices relevant to child health. In Brazil, IMCI was introduced in 1997, being largely restricted to training health workers in case management. IMCI training of doctors and nurses took place in many municipalities, but implementation of the other two components of IMCI was very limited. We analyze the impact of IMCI health worker training on infant mortality in three states in north-eastern Brazil, by comparing three groups of municipalities over the period 1999 to 2002: 23 with training coverage of 50% or greater, 216 with lower training coverage, and 204 without any IMCI training. Two sources of mortality data are used: vital registration of deaths and births, and the community health workers' (CHW) demographic surveillance system. The latter resulted in a larger number of deaths being reported and in more stable mortality rates over time than the former. Infant mortality rates (IMR) declined rapidly according to both sources of information, during the study period. After adjustment for confounding factors, there was no association between IMCI training coverage and infant mortality measured through either information system. According to the CHW data, the adjusted annual changes were of -7.2 deaths per 1,000 births in the high IMCI training coverage group, -4.6 in the low IMCI training coverage and -5.0 in the no IMCI group (p=0.46). According to vital statistics, the corresponding average annual changes were -5.0, -4.2 and -2.8 deaths per 1,000 births (p=0.16). The negative findings from the Brazil evaluation suggest that IMCI clinical training, in the absence of the other two components of IMCI, and in an area with infant mortality under 50 per 1,000, is unlikely to lead to a measurable impact on mortality.     

"Care" and public nutrition

In 1990, the Unicef conceptual framework for nutrition recognised the role of care, along with household food security and health services and environment, as one of the three underlying factors of child survival, growth, and development. This model has been adopted at a policy level at the International Conference on Nutrition (Rome, 1992) and over the past ten years the concept of care has been refined through literature reviews, consultative meetings and empirical works. "Care is the provision in the household and the community of time, attention, and support to meet the physical, mental, and social needs of the growing child and other household members". Basically, care refers to the actions of caregivers (mainly, but not only mothers) that translate food and health resources into positive outcomes for the child's nutrition. Even under circumstances of poverty, enhanced caregiving can optimise the use of resources to promote good nutrition. Care practices have been grouped into six categories: care for women, breastfeeding and child feeding practices, psychosocial care, food preparation, hygiene practices, household health practices. They cover a wide range of behaviours, are often culturally specific and are daily, repetitive, and time-consuming activities. It must be underlined that the way care practices are performed (i.e., quality of care) is as important as the practices themselves. It has also been emphasised that children play a significant role in determining the quality of care that they receive, through an interactive process: an active child elicits more care from the caregiver, who is in turn more responsive. Care resources at household level have been described according to three categories: human (knowledge, beliefs, education, physical and mental health of the caregiver), economic (control on income, workload and time), and organisational (alternate caregivers, community support). But the availability of care also depends on support at the national or international level. As the mother is the primary caregiver, most of the obstacles to care are the constraints to the mothers, the most common characteristic of which being the low status of women in many societies. More studies are required to better understand the causal relationship between care and nutrition. Methods to measure the qualitative aspects of care and indicators that capture the complexity of care must be developed and cross-culturally tested. These will also be useful to design and monitor more effective interventions incorporating care. These programmes should first identify and support the good traditional care practices rather than simply ask for change; the activities proposed should not break the balance between the time women spend on care and the time they spend on work. Therefore one must be sure that enough resources are available. Finally, to achieve sustainable changes a participatory and comprehensive approach is definitely needed.     

Impact of a community-based integrated management of childhood illnesses (IMCI) programme in Gegharkunik, Armenia

Background Maternal and child health status in the Martuni regionof Gegharkunik marz, Armenia, precipitously declined followingArmenia's independence in 1991. In response, the American RedCross (ARC) and the Armenian Red Cross Society (ARCS) implementedthe WHO community-level Integrated Management of Childhood Illnesses(IMCI) strategy, complementing recent clinical IMCI trainingin the region in which 387 community health volunteers from16 villages were trained as peer educators, and approximately5000 caretakers of children under age 5 were counselled on keynutrition and health practices. Methods A pre-post independent sample design was used to assessthe programme's impact. The evaluation instrument collectedrespondent demographic characteristics and knowledge, attitudesand practices consistent with 10 health indicators typical ofchild survival interventions. At baseline and at follow-up,300 mothers were interviewed using a stratified simple randomsampling of households with at least one child less than age2. Results The assessment confirmed the population's poor healthstatus and limited knowledge and application of recommendedchild care practices. The campaign reached its target: at follow-up,67% had seen media messages within the past month, 82% had receivedthe IMCI informational booklet, and 30% had seen other materials.Evidence of the success of the programme included the following:exclusive breastfeeding increased 31.4%, maternal knowledgeof child illness signs increased 30%, knowledge of HIV increased28.5%, and physician attended deliveries increased 15%. Conclusions This evaluation documented the significant and substantialimpact of the community IMCI programme on both knowledge andpractice in rural areas of Armenia. Consideration should begiven to continuing and expanding this project as a complementto health sector development activities in this region.     

儿童疾病综合管理早期实施研究

目的：分析儿童疾病综合管理（IMCI）早期实施阶段取得的及存在的问题，为进一步扩展提供指导。方法：根据WHO的评估方法，进行实施前的基础调查和实施后随访，比较分析二者的资料。结果：实施IMCI后，医务人员的病例管理水平，卫生机构的设备及药品供应以及家长的健康知识都有显著改善。结论：IMCI是加强儿童卫生服务的一个有效策略，应该根据中央和省级实施IMCI的能力继续加以扩展。     

河北省儿童疾病综合管理项目实施效果分析

目的:分析河北省儿童疾病综合管理项目实施取得的成绩及存在的问题,为项目进一步开展提供指导。方法:根据WHO的评估方法,进行实施前的基础调查和实施后随访及开展1年半后再次评估,分析比较前后资料。结果:实施IMCI后,医务人员的病例管理水平、卫生机构的设备及药品供应以及家长的健康知识都有显著改善。结论:IMCI是改善和加强儿童卫生服务的1个有效策略,应该继续执行和扩展。     

The societal value of vaccination in developing countries

The vaccination of children against childhood illnesses not only carries the obvious medical and economic benefits, but there exists numerous indirect and often far reaching added societal benefits. In developing countries, vaccination forms the basis of village operated primary health care (PHC) activities leading to a sustained PHC programme. Vaccination programmes provide an opportunity for the provision of other primary care services, as it can be the only recurring activity in primary care, that brings mother and child into contact with health services on a predictable and frequent basis. Vaccination leads to a direct and measurable reduction of child mortality rates and this has been proven to families and communities, resulting in families choosing to have fewer children. Vaccination becomes an opportunity for a higher standard of living as it encourages smaller families and in this way contributes to successes In family planning programmes. The vaccination of children has a great impact on the lives of women in developing countries as they are the principle carers of children. Protecting the lives of children directly through vaccination and through other PHC activities is a major strategy towards improving the lives of women as it liberates their time, energy and resources. The opportunity and provision of vaccination empowers women to protect their own health and that of their children through their own actions, giving an added psychological feeling of control and empowerment in their lives. Therefore, while vaccination services can be delivered alone, they are best delivered along with other services needed by children in their first year of life and by pregnant women: the persons who constitute the priority groups for primary health care services in the developing world. In addition to the monitoring of the growth of the child, the use of oral re-hydration to treat diarrhoea and the promotion of breast-feeding, these services may include malaria treatment and prophylaxis, and counselling with respect to child spacing, nutrition during pregnancy, weaning practices, and clean water and sanitation.     

Quality of care for under-fives in first-level health facilities in one district of Bangladesh

OBJECTIVE: The multi-country evaluation of Integrated Management of Childhood Illness (IMCI) effectiveness, cost and impact (MCE) is a global evaluation to determine the impact of IMCI on health outcomes and its cost-effectiveness. MCE studies are under way in Bangladesh, Brazil, Peru, Uganda and the United Republic of Tanzania. The objective of this analysis from the Bangladesh MCE study was to describe the quality of care delivered to sick children under 5 years old in first-level government health facilities, to inform government planning of child health programmes. METHODS: Generic MCE Health Facility Survey tools were adapted, translated and pre-tested. Medical doctors trained in IMCI and these tools conducted the survey in all 19 health facilities in the study areas. The data were collected using observations, exit interviews, inventories and interviews with facility providers. FINDINGS: Few of the sick children seeking care at these facilities were fully assessed or correctly treated, and almost none of their caregivers were advised on how to continue the care of the child at home. Over one-third of the sick children whose care was observed were managed by lower-level workers who were significantly more likely than higher-level workers to classify the sick child correctly and to provide correct information on home care to the caregiver. CONCLUSION: These results demonstrate an urgent need for interventions to improve the quality of care provided for sick children in first-level facilities in Bangladesh, and suggest that including lower-level workers as targets for IMCI case-management training may be beneficial. The findings suggest that the IMCI strategy offers a promising set of interventions to address the child health service problems in Bangladesh.     

Integrated management of childhood illness in resource-poor countries: an initiative from the World Health Organization

It is estimated that each year around 12 million children aged < 5 years die in resource-poor countries and that 70% of these deaths are due to communicable diseases and/or malnutrition. The same conditions are responsible for an even higher percentage of childhood illness. Since the mid-1990s the World Health Organization has been leading the development of an integrated approach to care for ill children at the primary care level, a programme know as Integrated Management of Childhood Illness (IMCI). The approach essentially combines improved management of childhood illness with aspects of nutrition, immunization and maternal health. IMCI replaces or complements a number of 'vertical' child health programmes aimed at specific groups of conditions including control of diarrhoeal diseases (CDD), acute respiratory infections (ARI) and the Expanded Programme on Immunization (EPI). As of late 1998 the programme, at various stages of development, had been introduced to 51 countries: Introduction (19 countries), Early Implementation (29 countries) or Expansion (9). The approach has many advantages not least that it is well accepted by tropical country paediatricians because it conforms to practice in secondary care. In some countries paediatricians are playing a greater leadership role than they did with previous specific programmes. Many problems remain: programmatic issues, probable over-diagnosis of malaria, relationships with other specific initiatives ('Roll Back Malaria' and new-born care) and how to integrate HIV infection into the diagnosis and care 'package'. However the initiative deserves support by paediatricians and public health specialists in industrialized countries.     

'Many voices, one song': a model for an oral health programme as a first step in establishing a health promoting school

Four health promoting (HP) schools were established in rural communities in Uganda by a joint Ugandan/Canadian university team. The model was based on a successful Canadian health promotion initiative designed to address poor oral health in Aboriginal children in rural and remote communities. Careful situation analysis, orientation of partner schools and collaborative development of educational materials and evaluation methodology preceded implementation. The intervention had three elements: inclusion of health topics by teachers in regular classroom activities; health education delivered by the university team to reinforce key educational concepts; and daily in-school tooth brushing to develop healthy practices. All children entering Grade 1 at four schools were recruited for 4 years; evaluation included year 1 pre-intervention and annual end-of-year data collection of quantitative and qualitative measures. Principal findings at 4 years included: an increase from baseline in the original cohort (n = 600) in those brushing at least once daily (p < 0.05) and before bed (p < 0.05); improved oral health (less 'bad breath', pain and absences for emergency dental treatment); more comprehensive health knowledge. Other positive observations were change in the schools' health culture; children sharing new health knowledge and advocating for health practices learned; and evolution of health promotion activity to address other community-identified issues following success with the initial oral health component. University faculty and students learned from participation in programme delivery and community-based educational opportunities. School-based health promotion using this oral health model was readily accepted, implemented, sustained and evaluated; all communities took ownership, and all schools continue their programmes. Addressing oral health through HP schools is novel in Africa, and several lessons learned are of potential value for similar health promotion initiatives in sub-Saharan Africa.     

Maternal/familiar knowledge in relation to care provided to sick children

Improving family and community practices is one of the components of the strategy Integrated Management of Childhood Illness (IMCI). Considering that In Brazil, IMCI is being implemented in the context of Family Health Program (PSF), the objective of this study was to identify maternal knowledge in relation to care provided to child with respiratory disease or diarrhea in two health units with different assistance models, with PSF and without PSF The results showed that the level of maternal/familiar knowledge were similar in both assistance models. Under a scientific point of view, the mothers/families showed overshot knowledge in relation to care provided to child with diarrhea. The finding show that mother and caretaker communication need to improve, even health units with PSF.